Sandro C. Esteves, MD, PhD Medical Director, ANDROFERT Campinas, Brazil The Role of Recombinant hCG in IVF 2 nd SGH SOAR, Singapore 2014
Jun 07, 2015
Sandro C. Esteves, MD, PhD Medical Director, ANDROFERT
Campinas, Brazil
The Role of Recombinant hCG in IVF
2nd SGH SOAR, Singapore 2014
Learning objectives At the completion of this presentation, participants should be able to: • Understand the differences between urinary
and recombinant hCG • Learn the clinical advantages of rec-hCG in
IVF as used for oocyte maturation triggering • Be aware of the additional potential use of
rec-hCG in other IVF-related conditions
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Human Chorionic Gonadotropin • Glycoprotein produced
during pregnancy by syncytiotrophoblast cells and by the pituitary in menopause women
• In early pregnancy, hCG rescues the corpus luteum and maintains progesterone production until placental steroidogenesis is established
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In IVF, hCG administration has been the gold standard for final follicular maturation as a surrogate for the mid-cycle LH surge
Extracellular fluid
Cytoplasm
Plasma membrane
LH hCG
LH/hCG receptor
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LH hCG No. AA beta subunit 121 145 Receptor binding affinity Low High* No. glycosylation sites1 1 6 Half-life (t ½) 20-30 min 24h Bioequivalency 6 – 8 IU 1 IU
1N-linked and O-linked glycosylation sites in beta subunit *2-3x higher than LH
Native LH and hCG are not identical “sisters”
Leao & Esteves. Clinics 2014;69:279-93.
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hCG and IVF - History • Zondek & Ascheim (1927)
found that urine of pregnant women contained a substance capable of inducing follicular maturation and ovarian stromal luteinization
• First hCG preparations developed in 1931 from urine of pregnant women
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Urinary hCG production The source: • Pooled urine from pregnant
women The process: • Urine pool is processed to
concentrate gonadotropins • hCG is extracted and purified
by either antibody affinity column or conventional chromatography
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ANDROFERT Source: Dr. Shelley Slaughter, FDA
Randomized 21-22 day old female rats
hCG injected sc 1x for 3 days
Sacrifice day 4 and collect ovaries
Ovaries are weighed and
data processed
Quantification of hCG activity based on rat ovarian weight gain
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ANDROFERT Steelman & Pohley Endocrinol. 53:604-16, 1953
Proportion of total immunoreactivity (%)
Pregnyl® Choragon® Profasi®
Intact bioactive hCG 50 30 96 Hyperglycosylated hCG 0.6 4 0.5 Free β subunit 6.2 8 2.4 β-core fragment1 43 58 1.2 Epidermal growth factor2 181-204 154 4-10
Yarram et al. Fertil Steril 2004;82:232-3
1degradation product of hCG; 2EGF is a contaminant (ng/5000IU)
Level of functionally intact hCG and contamination among formulations
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Non-gonadotropin proteins identified in u-hCG products
PLoS ONE 2011; 6(3): e17815
What is the ideal gonadotropin preparation?
• Originating from a safe and consistent source • Manufactured using consistent and
standardized processes • Fully physiochemically characterized • Effective • Favorable safety profile • Patient-convenient
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2001: rec-hCG (Choriogonadotropin alfa)
Adapted from Leao & Esteves. Clinics 2014;69:279-93
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Secretion of hCG molecules
Incorporation into host cell chromosome
Bulk hCG Released
Bulk hCG
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Purity (hCG content)
Specific activity (hCG/mg protein)1,2
Protein/IU (mcg = IU)
u-hCG <70% ~13,500 IU/mg ~550 = 5000
rec-hCG 99.9% 27,000 IU/mg 250 = 6750
1Bassett R et al Current Med Res Opinion 2005, 21:1969-76; 2Stenman U-H et al Br
J Pharmacol 2008; 154:569-83; Van Dorsselaer A et al PLoS One. 2011;6:e17815
u- hCG rec- hCG
CG beta CG alpha
Contaminants
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Size Exclusion High Performance Liquid Chromatography (SE- HPLC)
Gervais et al. Glycobiology 2003;13:179-189; Leao & Esteves Clinics 2014;69:279-93.
Filled by Mass Approach
Proven consistency of rec-hCG physiochemical characteristics
Consistent specific activity i.e. the same biological activity measured in IU/mg of protein
Approval to fill (vials, pens) by mass
(protein content in solution)
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rec- hCG
u- hCG: lyophilized powder to be reconstituted
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Rec-hCG has higher purity and better safety profile compared with u-hCG
Consistent physiochemical characteristics allow rec-hCG to be filled by mass, thus offering better dose precision and low batch-to-batch variation compared with u-hCG (filled by bioassay)
High specific activity of rec-hCG allows SC administration using a pre-filled syringe or a pen device while u-hCG needs to be reconstituted and is primarily indicated for IM route
Differences between urinary and recombinant hCG
Key points
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Clinical advantages of
rec-hCG in IVF as used for oocyte maturation triggering
Approved for use in the treatment of: • Adult women undergoing superovulation
prior to ART such as IVF to trigger final follicular maturation and luteinization after stimulation of follicular growth;
• Anovulatory of oligo-ovulatory women to trigger ovulation and luteinization after stimulation of follicular growth.
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250 μg rhCG=6,500 IU; SC
10,000 IU uhCG; IM
5,000 IU uhCG; IM
Seru
m h
CG
leve
ls
Trinchard-Lugan et al., 2002 Itskovitz et al., 1991
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0% 20% 40% 60% 80% 100%
Doctors & embryologists
Nurses
Patients Safety
Effectiveness
Patient-centeredness
Hum Reprod 2013;26(6):1584-97
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r-hCG (250 mcg)
r-hCG (500 mcg)
u-hCG (10,000 IU)
No. patients 94 89 92 Oocytes retrieved (mean) 13.6 14.6 13.7 2PN fertilized (mean) 7.2 8.8 P=0.02 7.8 Serum P (d6-7 after hCG) 133.0 163.5 P=0.03 147.4 Pregnancy rate (%) 35.1 36 35.9 OHSS (%) 3.2 9.0 3.1
Chang et al. Fertil Steril. 2001; 76: 67–74
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RCT N Effect Oocytes retrieved 9 1409 MD: -0.04 (95% CI -0.69 to 0.61)
Live birth 6 1,019 OR: 1.04 (95% CI 0.79 to 1.37)
Miscarriage 7 1,106 OR: 0.69 (95% CI 0.41 to 1.18)
Severe OHSS 3 549 OR: 1.49 (95% CI 0.54 to 4.1)
Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719.
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Databases searched up to January 2010
Farrag et al. JARG 2008; 25:461-6.
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8.4 7.3 7.1 4.7
0 2 4 6 8
10
No. Retrieved oocytes No. MII with mature cytoplasm
rec-hCG (250 mcg; n=42)
u-hCG (10,000 IU; n=47)
*p<0.01 *
Effectiveness RCT comparing rec-hCG (250 mcg) with u-hCG (10,000 IU) for oocyte maturation triggering on
delivery rates in eSET antagonist cycles
26.7% 44.1%
Delivery rate (%)
10,000 IU u-hCG 250 mcg rec-hCG
N=119 aged<32
OR: 2.16 (95% CI: 1.01-4.67; p=0.04) Papanikolaou EG et al. Fertil Steril 2010; 94:2902-4
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Saleh L et al. Placenta. 2007;28(2-3):199-203
• In vitro treatment of trophoblast cells with different hCG products
• Phosporilation of EGC receptors after u-hCG treatment, but not with rec-hCG
• Increased trophoblast invasion and syncytialization observed using EGF-free hCG (rec-hCG) compared with u-hCG (EGF-contaminated)
Urinary and rec-hCG differentially impact trophoblast differentiation
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RCT N Odds-ratio
Local site reactions* rec-hCG vs. u-hCG 3 374 0.39
95% CI: 0.25 to 0.61
Driscoll et al. 2000: 27% vs 42% ERHCG Group 2000: 23% vs 45% Abdelmassih et al. 2005: 23% vs 45%
Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719.
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* Pain and/or inflammation
Human errors after hCG administration
• 0.5%-0.8% Empty follicle syndrome after u-hCG administration1,2
• Case report of patient who injected only diluent3
• Recurrent empty follicle syndrome successfully treated with rec-hCG4
1Quintans et al. Hum Reprod 1998;13:2703-5; 2Zegers Hochschild et al. Hum Reprod 1995;10:2262-5; 3Esposito & Patrizio J Reprod Med 2000;45:511-4;
4Penarrubia et al. Hum Reprod 1999;14:1703-6.
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hCG preferences in treatment-experienced patients at Androfert
Total (n=76) 60% 29%
3%
8%
prefer new pen prefer pre-filled syringe prefer lyophilized powder to reconstitute Not matter
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• Safety originates from a safe and consistent contamination-free source; fully characterized
• Effectiveness 250 mcg rec-hCG at least as effective as 10,000 IU u-hCG for final follicular maturation
• Patient-centeredness better tolerated and preferred by treatment-experienced patients
Clinical advantages of rec-hCG in IVF for oocyte maturation triggering
Key points
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Additional possibilities for using rec-hCG in IVF
• Male Infertility • Luteal phase
support • Intrauterine
administration
1Shiraishi et al Hum Reprod 2012;27(2):331-9; Esteves Int Braz J Urol 2013;39(3):440
hCG in non-obstructive azoospermia prior to sperm retrieval
Microdissection TESE
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• Rescue ~15% of patients with failed SR attempts1
Modified LPS for fresh ET in GnRH-a trigger using hCG
No. follicles day OPU 1,500 IU hCG at OPU & 1,000
OPU+5 & standard LPS ≤ 14 1,500 IU hCG at OPU +
standard LPS 15-25 1,000 IU hCG at OPU +
standard LPS or Freeze all 26-30
Freeze all >30
14h
14h 20h
48h 0 20 h
4h
GnRHa Natural
Luteal phase defect
LH Surge
Humaidan et al. Hum Reprod. 2013;28(9):2511-21
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Intrauterine hCG administration (500 IU) before embryo transfer
Positive effect on endometrial receptivity1 • Inhibition of IGF-binding
protein 1 and M-CFS • Stimulation of LIF, VEGF,
MMP-9
1Licht et al Hum Reprod Update 1998; 2Mansour et al Fertil Steril 2011; 3Santibañez et al Reprod Biol Endocrinol 2014
Improvement in implantation and pregnancy rates
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Rec-hCG produces pharmacodynamic responses consistent with hCG physiology, thus offering the opportunity for use in the same clinical situations as u-hCG
The secure source and high purity of rec-hCG may offer advantages when used for male infertility, luteal support and intrauterine administration
Although preliminary data seems promising, safety, effectiveness and patient-centeredness still need to be evaluated in large RCT trials
Additional possibilities for using rec-hCG in IVF
Key points
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